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HomeMy WebLinkAbout2024-00069829 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110110 0 OH 1011111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40361.4&98 u, 1 U29 2 4 1 U, 2 U2 1 U, 1 U299 U, 1 U2 99 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00069829 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME BENT ST Elgin SECONDARY CRASH 15 ® ❑ RELATED ' V 0 N 11 02 2024 01:03 ❑AM CI YES 0 NO U1 -< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W S LIBERTY ST COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 99 Cl) ❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 7 ! yr 13-UNDER CARRIAGE ©i FIRE El < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 M M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _ El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, i�6 �i 4 COM VEH 0 Z� 1 0 H 1- PINGREE GROVE IL 60140-9155 C 1 FIRST CONTACT 11 T_: __s *IrYes.seeSidebar Ut Z DH79050 IL 2025 E TELEPHONE IL D 5N MZTDLB3J H 108018 Progressive ❑Y Igl N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 988303204 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m,lv 0 Ncv 0 Dv yr 12 _13-UNDER CARRIAGE 10 2 FIRE 0 El 0U2 C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 SYSTEM IN ENGAGED 15-OTHER 9.16-TOP 3 9 a 9 9 0 Y ❑N ❑UNK VEH. AT CRASH ® UNKNOWN `Distraction Value POINT OF 8 4 ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 1 Y ;:=s •COMf •Sidecar❑ ® C 0 CO 9 T7FAR 9 M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 Unknown 0 Y 0 N RDEF Xl EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same Unknown BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE( (EMS) (HOSPITAL) U1 1 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 11 /02 l2024 01 03 ®PM in a Work Zone? ®N DIRP co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) T 0 2 ❑ 2 99 / / ❑PM ❑Construction Z 3 ❑ ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 —a, ARREST NAME / / ❑PM ' oN ® 11 `1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ,....Utility SLMT T 2 ❑ ARREST NAME AM T / / pM ❑Unknown work zone type 30 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 414 Cara. Saul 401 275-Engelke / / ❑PM ®N U2 REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS! A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE even if units have been moved prior to officer's arrival. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS. r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< c ` -'- ' r INDICATE NORTH combination):or .Z-1 A C BY ARROW 2 Is used ordesi nedtotran transport g sp passengers including the driver I- 0 I (example:shuttle or charter bus):or 0 < <----�;-•-•; - -- - - - I • transporting rtig o l5 or fewer in the course of he r rs employment example:employee a contract Not To Scate [0--- r r r '" `�employeesp'0 transporter-usually a van type vehicle or passenger car):or w i. L.___a._._J __. } 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C '_- i } } for direct compensation(example:large van used for speific purose):or 0 r t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m i I XIr�r placarding(example:placards will be displayed on the vehicle). - —1 - CARRIER NAME Z I .......r ADDRESS 0 CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El Unknown C Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7 MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Tan u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO. DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE